A nurse is caring for a client who has a chest tube that was inserted 4 days ago. Which of the following findings should the nurse report to the charge nurse?
Respiratory rate 16/min
Blood pressure 110/70 mm Hg
400 mL of drainage in the collection chamber within 4 hr
Fluctuation in the water seal chamber with respiration
The Correct Answer is C
A. Respiratory rate 16/min is a normal finding. A respiratory rate of 16/min is within the expected range for adults, so it does not indicate a problem that requires immediate attention.
B. Blood pressure 110/70 mm Hg is within the normal range for blood pressure. This is an acceptable finding and does not require reporting to the charge nurse.
C. 400 mL of drainage in the collection chamber within 4 hr should be reported to the charge nurse. This is an excessive amount of drainage for a client with a chest tube. After the first few hours post-surgery, the drainage should decrease. Large amounts of drainage may indicate bleeding, and it is important to notify the charge nurse immediately to assess the situation further.
D. Fluctuation in the water seal chamber with respiration is a normal finding. It is expected for the water seal chamber to fluctuate with the client’s respirations, indicating that the chest tube is functioning properly and the system is not obstructed.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Patient care technician is incorrect. A patient care technician (PCT) is typically responsible for assisting with basic care tasks, such as taking vital signs or helping with personal hygiene. A PCT is not qualified to assess or manage medication interactions.
B. Psychologist is incorrect. A psychologist specializes in mental health and behavior but does not have the expertise to manage or review medication interactions.
C. Advanced practice nurse is correct. An advanced practice nurse (APN), such as a nurse practitioner, has advanced education and training in pharmacology and the management of complex medication regimens. They can assess potential medication interactions and provide guidance on safe medication use.
D. Social worker is incorrect. While a social worker provides support in areas like coping with illness and accessing resources, they are not typically involved in managing or reviewing medication interactions.
Correct Answer is C
Explanation
A. "Self-administer oxygen through your nasal cannula at 6 milliliters per minute during meals." is incorrect. Oxygen should not typically be increased during meals unless specifically prescribed by the provider. If the client has difficulty eating due to breathlessness, a more individualized plan is needed.
B. "Drink at least 240 milliliters of water during each meal." is incorrect. Clients with COPD may have difficulty breathing when consuming large amounts of fluids during meals. Overhydration could also worsen fluid retention in some cases. The amount of fluid should be tailored to the client’s needs and prescribed by the healthcare provider.
C. "Perform pulmonary hygiene 1 hour before meals." is correct. Pulmonary hygiene (such as postural drainage, coughing techniques, and deep breathing exercises) should be performed before meals to clear the airways and improve the ability to breathe while eating, preventing aspiration and difficulty breathing.
D. "Lie down for 30 minutes after eating." is incorrect. Lying down after eating can increase the risk of aspiration, especially in clients with COPD who may already have a compromised respiratory system. The client should be advised to remain upright after meals to prevent reflux and aspiration.
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